- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $204.17
| Professional | | $91.20 | $112.20 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $162.18
| Professional | 26 | $54.95 | $69.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $44.67 / $89.13
| Professional | TC | $28.18 | $44.67 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $131.83 / $186.21
| Professional | | $75.86 | $131.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $72.44 / $102.33
| Professional | 26 | $50.12 | $72.44 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $21.38 / $50.12 / $72.44
| Professional | TC | $21.38 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $70.79 / $151.36
| Professional | | $56.23 | $70.79 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $95.50
| Professional | 26 | $89.13 | $93.33 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $57.54 / $57.54
| Professional | TC | $54.95 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $128.82 / $158.49
| Professional | | $112.20 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $70.79 / $85.11
| Professional | 26 | $60.26 | $70.79 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $58.88 / $70.79
| Professional | TC | $51.29 | $58.88 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $275.42
| Professional | | $97.72 | $134.90 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $72.44 / $100.00
| Professional | 26 | $60.26 | $72.44 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $42.66 / $70.79
| Professional | TC | $29.51 | $42.66 | $70.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $138.04 / $229.09
| Professional | | $85.11 | $138.04 | $229.09 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $74.13 / $131.83
| Professional | 26 | $53.70 | $74.13 | $131.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $56.23 / $77.62
| Professional | TC | $36.31 | $56.23 | $77.62 |